PUTNAM CITY SCHOOLS: DISTRICT FORM

EN-F1

STUDENT DRUG TESTING CONSENT:

ACTIVITY STUDENTS
Student Printed Name: _____________________________________________ Grade:_______________
Student ID Number:__________________ Date of Birth:__________________ Graduation Year:_______
Activity:_____________________________________________________________________________
_
Student Consent:
I have read and understood the Student Drug Testing Policy and Student Drug Testing Consent. I
understand that, out of care for my safety and health, District enforces the rules applying to the
consumption or possession of illegal and/or performance-enhancing drugs. If I choose to violate school
policy regarding the use or possession of illegal and/or performance-enhancing drugs any time while I am
involved in in-season or off-season activities, I understand upon determination of that violation I will be
subject to the restrictions on my participation as outlined in the Policy.
_______YES, I CHOOSE TO PARTICIPATE IN THE DRUG TESTING PROGRAM.
_______NO, I CHOOSE NOT TO PARTICIPATE IN THE DRUG TESTING PROGRAM.
Note: By selecting not to participate in the Drug Testing Program, I understand that I will not be
able to participate in any activity covered under this policy.
Student Signature: ___________________________________________ Date: __________________
Parent Consent:
I have read and understood the Student Drug Testing Policy and Student Drug Testing Consent. I desire
that the student named above participate in the extra-curricular interscholastic programs of District, and I
hereby voluntarily agree to be subject to its terms. I accept the obtaining of saliva samples, testing and
analysis of such specimens, and all other aspects of the program. I further agree and consent to the
disclosure of the sampling, testing and results as provided in this program.
______YES, I AGREE TO THE TERMS OF THIS POLICY.
______NO, I DO NOT WANT MY SON/DAUGHTER TO BE TESTED ACCORDING TO THE
TERMS
HIS POLICY.
Note: By selecting not to participate in the Drug Testing Program, I understand that the student named
above will not be able to participate in any activity covered under this policy.
Printed
Parent/Guardian
______________________________________________________________
Parent/Guardian Signature: _________________________________

7/14, 11/14

Name:

Date:
______________________